A nurse is providing discharge teaching to a client who is taking warfarin. Which of the following information should the nurse include in the teaching?

Take this medication at the same time each day.

Take ginger for constipation while on this medication.

Eat foods high in vitamin K.

Shave with disposable razors.

Answer and Explanation

The Correct Answer is A

A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.

B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.

C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.

D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.

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Correct Answer is D

Explanation

A. "Empty the drainage bag every 12 hours.": Urine should be emptied regularly, but not on a fixed 12-hour schedule. The focus is on preventing backflow and maintaining sterility, so the bag should be emptied when it is two-thirds full or as needed, rather than strictly every 12 hours.

B. "Irrigate the indwelling urinary catheter once per shift.": Routine irrigation is not recommended for preventing catheter-associated urinary tract infections (CAUTIs) and can introduce pathogens or cause trauma. Irrigation should only be performed if specifically indicated for obstruction or provider order.

C. "Apply a topical antimicrobial ointment as part of routine catheter care.": Routine application of antimicrobial ointment is not recommended and does not prevent CAUTIs. Proper hygiene and sterile technique are more effective in infection prevention than topical agents.

D. "Keep the drainage bag below the level of the bladder.": Maintaining the drainage bag below the bladder prevents backflow of urine, which is a major risk factor for introducing bacteria into the urinary tract. This simple intervention is a key measure in reducing catheter-associated urinary tract infections.

A. Client reports popping sensation at the wound B. Client is tender to touch at the surgical site C. Crusting on the client's incision line D. serosanguineous drainage on the client's dressing

Correct Answer is A

Explanation

A. Client reports popping sensation at the wound: A popping or tearing sensation at the surgical site can indicate wound dehiscence or evisceration, which is a surgical emergency. Immediate reporting to the provider is essential for prompt intervention to prevent further complications.

B. Client is tender to touch at the surgical site: Mild tenderness is expected 24 hours postoperatively due to inflammation and tissue trauma. While it should be monitored, it is not an urgent finding requiring immediate provider notification.

C. Crusting on the client's incision line: Light crusting is a normal part of the healing process and does not typically indicate a complication. Routine wound care and monitoring are sufficient.

D. Serosanguineous drainage on the client's dressing: Serosanguineous drainage is expected within the first 24–48 hours after surgery. It is a normal finding and usually does not require urgent reporting unless it increases significantly or changes character.

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A nurse is providing discharge teaching to a client who is taking warfarin. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

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